Scientific Foundation SPIROSKI, Skopje, Republic of Macedonia
Open Access Macedonian Journal of Medical Sciences. 2021 Aug 03; 9(F):260-274. https://doi.org/10.3889/oamjms.2021.6234
eISSN: 1857-9655
Category: F - Review Articles
Section: Systematic Review Article
The Impact of Online Game Addiction on Adolescent Mental Health:
A Systematic Review and Meta-analysis
Eni Purwaningsih1, Ira Nurmala2*
Department of Health Promotion and Behavioral Sciences, Master Program of Public Health Sciences, Faculty of Public
1
Health, Universitas Airlangga, Surabaya, Indonesia; 2Department of Health Promotion and Behavioral Sciences, Faculty of
Public Health, Universitas Airlangga, Surabaya, Indonesia
Edited by: Eli
Djulejic Citation: Purwaningsih E, Nurmala I. The Impact
of Online Game Addiction on Adolescent Mental Health: A
Systematic Review and Meta-analysis. Open Access Maced
J Med Sci. 2021 Aug 03; 9(F):260-274.
https://doi.org/10.3889/oamjms.2021.6234
Keywords: Adolescent; Good health and wellbeing;
Mental health; Online game addiction
*Correspondence: Ira Nurmala, Faculty of Public
Health - Universitas Airlangga, Surabaya, Indonesia.
E-mail: iranurmala@fkm.unair.ac.id
Received: 19-Apr-2021
Revised: 19-May-2021
Accepted: 24-Jul-2021
Copyright: © 2021 Eni Purwaningsih, Ira Nurmala
Funding: This research did not receive any financial
support
Competing Interest: The authors have declared that no
competing interest exists
Open Access: This is an open-access article distributed under
the terms of the Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0)
Background
Digital technology is currently advancing rapidly,
making it easier for everyone to connect and share the same
interests without any obstacles across geographic and
temporal boundaries, convenient, flexible to reach, and
affordable in developed countries; from these many
advantages, there are also concerns among researchers
related to the use of digital technology exaggerated [1]. One
of the digital technologies that are currently in existence is
online games. Online game games are currently booming
among adolescent worldwide, even
tournaments/competitions are held in playing them, which
are integrated by the players’ social networks. Internet
addiction (IA) is currently considered a global problem with
possible implications for mental health [2], [3].
The way people interact with technology is
constantly changing. New behaviors have improved, social
and recreational activities have changed, and new
psychological problems have arisen. In the late 1990s,
concerns about addictive internet use were
Open Access Maced J Med Sci. 2021 Aug 03; 9(F):260-274.
Abstract
BACKGROUND: The World Health Organization in 2019 determined internet gaming disorder (IGD) to be mental health
disorder. Among adolescents, excessive online gameplay has become a lifestyle. It associated with psychological symptoms
(psychopathological symptoms and life satisfaction), social health (social interactions), and physical health (general health
and body mass index). The emergency department has now become a global problem.
AIM: This study aims to analyze the impact of online game addiction on adolescents using the Preferred Reporting Items for
Systematic Reviews (PRISMA) approach.
MATERIALS AND METHODS: Subjects were searched extensively in PubMed, Sage, Science Direct, and Scopus
databases. Searches used the keywords “online game addiction,” “mental health,” and “adolescent.” The inclusion criteria in
the Pustaka study are the type of source journal, the article is written in English, the full text is available, the publication year
limit is 2011–2021, and the subject’s age is 13–18 years old.
RESULTS: We identified 81 articles, of which 20 were deemed relevant for this systematic review. This review study shows
that problematic online gaming behavior has strong negative correlation with various subjective health outcomes. Further
analysis using Review Manager 5.3 for meta-analysis showed that adolescents with online game addiction could increase
mental health disorders by 1.57 times than adolescents without online game addiction (adjusted odd ratio = 1.57 (1.28–1.94);
p ≤ 0.001.
CONCLUSION: Early prevention efforts relevant to adolescents from the IGD, namely, the wise use of the internet/ gadgets,
are the only option to avoid or reduce the symptoms of internet addiction and online games.
discussed, and, since then, the concept has been widely studied
and debated. Although it has been treated form different
angels and researchers have used additional
terms, “internet addiction” has become one of the most
commonly used terms, along with “internet use is
problematic” [4]. As the social problem of online gaming
addiction has become widespread, online gaming has
become viewed negatively such as gambling or alcohol
addiction [5]. With the rapid surge in the population of
internet users, IA has become an increasing mental health
problem worldwide, raising public concern [2]. Healthily
using the internet can be understood as achieving the
desired goal in an appropriate time frame without
experiencing any intellectual or behavioral discomfort [6].
IA is described as an individual’s inability to control their use
of the internet, which causes disruption and disruption in
fulfilling work, social, and personal commitments and
appears to have similarities with the category other aspects
of behavior and substance use [6].
Since their commercial introduction in the 1970s,
video games have become an integral part of modern leisure
and entertainment. In particular, internet video
1
F - Review
games, particularly massively multiplayer online (MMO)
games, have gained increasing research attention based on a
compelling combination of functionality, socialization and
development of play have many positive benefits and may
improve endurance, spatial visualization, problem solving,
communication skills, as well as educational and therapeutic
benefits. However, the harmful effects of excessive gambling
in a small group of individuals have also been demonstrated
experimentally. This can include increased aggressive
behavior and preoccupation, increased impulsivity and a
tendency to play addictive games. Stavropoulos research
investigating the adverse effects of gaming has led to
developing and introducing diagnostic terminologies such
as internet gaming disorder (IGD) and IA [7].
According to Nie et al., 2002 [9], about “bad
internet” versus “good internet” is the current debate by
reviewing the influence of internet use on social skills. The
essence of socializing is personal interaction (face to face) and
friendliness. On the one hand, the internet leads to more and
better social relations by creating another medium of
communication to friends and family and seeking new
relationships without geographical, cultural, and time
boundaries. However, on the other hand, it is predicted
that internet use can be socially isolating because time in
using the internet often sacrifices social activities and face-
to-face interpersonal interactions [8].
Tateno et al. 2019, in his research, found that the
trend of men preferring games in their internet usage. At the
same time, women use the internet mainly for social
networking through smartphones, and the average SAS-SV
score (the Smartphone Addiction Scale [SAS]-Short Version)
higher in women. According to the primary purpose of
internet use, a two-group comparison between gamers and
social media users shows that gamers use the internet longer
and have significantly higher average the internet addiction
test (IAT) and HQ-25 scores [9].
During adolescence, new developmental tasks can
pose significant challenges and psychological stress to the
adolescent. In addition to practical problem-solving strategies,
dysfunctional stress management strategies are often used
to address these developmental tasks while also dealing
with the struggle for freedom (from parental restraints, for
example) or self-discovery. Given the pervasive pattern of
problematic behaviors associated with adolescent digital
media use, it seems quite appropriate to test whether there is
an empirical relationship [10]. Addressing the issue of online
gaming and the issue of mental health consequences
children and adolescents playing online games is important
given the usual trajectory of neurodevelopment;
adolescence is characterized by increased maturation of the
limbic system, which makes adolescents more likely to
engage in addictive behavior than adults [11]. Therefore,
this study set out to systematically examine the impact of
online game addiction behavior on adolescent mental
health.
2 https://oamjms.eu/index.php/mjms/index
Systematic Review
This systematic review research and meta-
analysis raised the theme of the impact of online game
addiction on adolescent mental health. The independent
variables analyzed were online game addiction. Research
that discusses data on online game addiction is considered
important because of its rarity. The dependent variable
analyzed is adolescent mental health. The number of
relevant research published and accessible is still small and
also has data access problems [12]. Most of the statistical
results reported are in percentage, correlation or only
significant (p-value), where the study does not control for
confounding factors (confounding factors).
Confounding factors affect the relationship or
effect of exposure to the occurrence of the disease estimated
by the study that is not the same as the relationship or effect
that actually occurs in the target population, so that the
outcome invalid studies [12]. This systematic study and
meta-analysis uses studies that control the confounding
factors that can be seen from the research inclusion
requirements, namely, using multivariate analysis and the
statistical results reported are adjusted odd ratio.
The combined estimate of the impact of online
game addiction on adolescent mental health was processed
using the RevMan 5.3 application with the generic inverse-
variance method [13], [14]. This method is used to analyze
data in the form of rate, time to event (time-to-event),
hazard ratio (hazard ratio), ordinal scale, adjusted estimate
(adjusted estimate), and difference of mean or ratio of
mean.
The results of systematic studies and meta-
analyses are presented in the form of forest plots and
funnel plots. The forest plot shows visually the magnitude
of variation (heterogeneity). The funnel plot shows the
relationship between the study’s effect size and the sample
size of the various studies studied, which can be measured
in different ways [12].
Various studies have been conducted to reduce the
risk and impact of online game addiction on adolescent
mental health. And also most of the existing research is based
on schools and adolescents, so this study looks at the impact
of online game addiction on adolescent mental health, but the
results of the research still do not show consistent results.
Further analysis is needed to get a convincing conclusion
regarding the impact of online game addiction on
adolescent mental health using a systematic review and
meta-analysis.
Methods
Strategies for finding relevant studies
Articles published in English are searched on
PubMed, Science direct, Sage and Scopus. Relevant
 F - Review Systematic Review

literature was searched from February to March 2021.
Publication time is limited to 2011–2021. Search terms
were “online game addiction,” “mental health,” and
“adolescent.” The technique used for keywords uses
Boolean operators and truncation to broaden and narrow the
search. Results from four databases yielded 81 articles. As
the initial layer, the title and abstract are read and filtered
independently by the main author and checked by the
second author. Any articles that are not relevant to the
topic of online game addiction are immediately removed.
Inclusion criteria include journals in English published in the
past ten years, data collected both qualitatively and
quantitatively or a combination of both, focus of study on
adolescents 13–18 years, and the full text is available.
After being collected, 81 articles were carefully
examined for relevance so that 20 articles were finally
selected to be included in the scoping review of this journal.
The last collection of articles was tabulated, and the main
findings of each article were mapped to share the latest
knowledge about online gaming addiction. The following
data were taken from each article: Author, year and place of
study, study design, and the primary purpose of the study.
Guided by research questions, what are the characteristics
of online game addiction symptoms and their implications for
adolescents’ mental and physical health. The articles are then
compared and grouped into broad categories. Eighty-one
articles were carefully examined for relevance so that 20
articles were finally selected to be included in the scope
review of this journal. The last collection of articles was
tabulated, and the main findings of each article were
mapped to share the latest knowledge about online gaming
addiction. The following data were taken from each article:
Author, year and place of study, study design, and the
primary purpose of the study. Guided by research questions,
what are the characteristics of online game addiction
symptoms and their implications for adolescents’ mental
and physical health. The
online game addiction symptoms and their implications for
adolescents’ mental and physical health. The articles are then
compared and grouped into broad categories. The last
collection of articles was tabulated, and the main findings of
each article were mapped to share the latest knowledge
about online gaming addiction. The following data were
taken from each article: Author, year and place of study,
study design, and the main purpose of the study. Guided by
research questions, what are the characteristics of online
game addiction symptoms, and their implications for the
mental and physical health of adolescents. The articles are
then compared and grouped into broad categories.
Results
Results that the results obtained from 20 articles
analyzed showed that almost all articles discussed and
showed results about the impact of online game addiction
on adolescent mental health. This impact does not only
occur in adolescents, but also in adults. The results of the
analysis also found that family relationships play an
important role and maybe one of the risk/protective factors
associated with the IGD, which has been explored as
perceived family disharmony, parental inconsistency, family
dysfunction, poverty, and family relationship problems
[15].
Review several articles also explain the risk
factors and symptoms of the emergency department. They
also explain the prevention and treatment of the emergency
department and policy recommendations for handling the
emergency department in the field of public health. Based on
the 20 articles analyzed (Table 1 and 2), seven studies (35%)
were studies in 2019.

Table 1: General characteristics of selected studies (n=20)

articles are then compared and grouped into broad
categories. Eighty-one articles were carefully examined for Category n %
Publish year
relevance so that 20 articles were finally selected to be 2011 - -
2012 - -
included in the scope review of this journal. The last 2013 - -
collection of articles was tabulated, and the main findings of 2014 1 5
2015 1 5
each article were mapped to share the latest knowledge 2016 -
about online gaming addiction. The following data were taken 2017
2018
2
2
10
10
from each article: Author, year and place of study, study 2019 7 35
2020 6 30
design, and the main purpose of the study. Guided by 2021 1 5
research questions, what are the characteristics of online Total 20 Articles 100%
Research location (country)
game addiction symptoms and their implications for Italy 1 6.7
adolescents’ mental and physical health. The articles are Spanish
India
2
1
13.3
6.7
then compared and grouped into broad categories. The last Germany 2 13.3
Korea 2 13.3
collection of articles was tabulated, and the main findings of Hong Kong 1 6.7
each article were mapped to share the latest knowledge Taiwan 2 13.3
Finland 1 6.7
about online gaming addiction. The following data were Saudi Arabia 1 6.7
taken from each article: Author, year and place of study, Belgium
United Kingdom
1
2
6.7
13.3
study design, and the main purpose of the study. China 1 6.7
Turkey 1 6.7
Guided Spain 1 6.7
by research questions, what are the characteristics of Germany & Austria
Total
1
20 Articles
6.7
100%

2 https://oamjms.eu/index.php/mjms/index

Type of game online
addiction
Problematic internet use (PIU)
There are many terms and concepts regarding PIU
in the existing literature. When first introduced by
Young, “Internet Addiction” was the most common term, as
the diagnostic criteria proposed were based on the measures
applied to the disease. However, in the absence of a
prolonged formal diagnosis, the study by Lai and Kwan’s
2017 switched to the use of other terms or definitions such
as “problematic internet use” (PIU) and “compulsive
internet use” to avoid confusion with psychiatric disorders.
Identified in Study I, there is an indirect negative effect of
family income on PIU through better relationships with
teachers, leading to greater use of the internet in learning
and therefore better learning outcomes. The early stages of
mediation are not a surprising finding, as the previous
research has shown that students from older families tend to
have better relationships with teachers and better
interpersonal relationships in general, possibly due to more
developed social and communication skills [16].
IA
IA can be defined as the inability to control one’s
internet use with negative consequences and long term for a
considerable time [17]. However, there is no general
consensus on the definition of IA. Research shows that
addiction is actually linked to the use of certain online
activities, meaning that each addiction is characterized by a
certain behavioral behavior according to this viewpoint
considers certain common elements in the spectrum of
addiction must be recognized as impulsive personality and
addictive personality [17].
IGD
The definition of game addiction refers to the
excessive and compulsive use of video games resulting in
social and emotional problems; despite these problems, and
the player cannot control the use of video games [5].
Increase in the time and frequency of online games can lead
to negative consequences, the most consequences discussed
consequences in the scientific literature being IGD and
aggressive behavior in boys playing certain actions. IGD
was recently introduced in the Nosology textbook as an
addictive behavior disorder. The International Classification
of Diseases 11th edition (ICD-11) considers IGD among
addictions beyond the fact that addictive behavior involves
the use of psychostimulants and is characterized primarily by
greed. Repeated and continuous engagement in online
games results in clinically severe pain, with a broad
spectrum of psychological problems including depression,
anxiety, social phobia, poor school performance
(achievement), and sleep deprivation[18], [19], [20].
Open Access Maced J Med Sci. 2021 Aug 03; 9(F):260-274.
Purwaningsih and Nurmala. Online Game Addiction on Adolescent Mental
The American Psychiatric Association (APA)
definition of IGD in the Diagnostic and Statistical
th
Manual of Mental Disorders (DSM-5) 5 Edition follows
the criteria for substance abuse and problem gambling.
1. Having fun with gambling
2. Withdrawal symptoms from not playing the game
3. Tolerance, need to spend more time gambling
4. Unable to stop or control gambling
5. Loss of interest in recreational activities other than
games
6. Continuing to play despite psychosocial problems
7. Lying and deceiving others about games numbers
8. Using video games to escape negative moods or
life problems real life
9. Loss or risk of losing meaningful relationship,
career, or educational opportunity as a result of
gambling.
In the latest edition of the ICD-11, online gaming
behavior is included as a diagnosis including addiction
disorders. In ICD-11 gaming disorder is characterized by
persistent or repetitive patterns of digital gaming or
video game behavior that may manifest online or offline as.
1. Impaired control over game (e.g., onset,
frequency, intensity, stopping duration, and
context)
2. Increase the priority given to playing games in the
sense that games take precedence over daily
interests and activities over other life
3. Continuation or escalation of the game despite
negative consequences [21].
The above behavior patterns are quite severe
enough to cause significant damage in the areas of personal,
family, social, educational, work, or other essential
functions [22].
According to research by Fernández-Villa et
al., 2015 [23], found a significant relationship between
several health problems (migraine, back pain, overweight
or obesity, and insufficient rest), psychological aspects (risk
of eating disorders, risk of mental disorders, and
depression), family problems and discrimination, without
any association with substance use (alcohol, marijuana, or
tobacco) was found. However, for some players, overuse
fosters dependence, leading to negative psychosocial and
health consequences konsekuensi [24].
A literature review conducted by Mihara and
Higuchi found that the prevalence of IGD ranges from 0.7%
to 27.5%, depending on the sample. The rate is higher for
men than for women and tends to be higher for young people.
The prevalence rates found in different studies also vary
slightly from country to country. Factors associated with IGD
are gambling characteristics, demographic variables, family
socioeconomic level, and academic performance [25].
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 F - Review
IA/addiction (such as online gaming) has
detrimental effects on the lives of adolescents, such as
reduced academic performance, physical and mental health
and adolescent relationships. Therefore, monitoring internet
usage behavior such as online gaming among adolescents is
necessary for early detection of IA. IGD is associated with
well-documented psychological distress. For example, the
IGD has been associated with depression, anxiety,
obsessive- compulsive behavior with inattention,
hyperactivity, low self-esteem, loneliness, and social
phobia [26], [27]. A study in India stated that depression is
a major comorbid disorder of IA, self-esteem is an
individual’s attitude toward himself which can be positive or
negative and is understood as one of the core components of
depression. Thus, individuals with irrational cognitive
assumptions about themselves are likely to have lower self-
esteem and tend to engage in addictive behaviors that help
them temporarily break away from their cognitive premises
about themselves [5].
In a study conducted by Niko Mannikko, Joel
Billiex and Maria Kaariainen Oulu with the topic
“Problematic digital gaming behavior and its relation
to the psychological, social and physical health of
Finnish adolescents and young adults” the results
showed a significant relationship between fatigue,
depression, anxiety, trouble sleeping, and problems when
focusing on problem gaming scores (online game addiction)
[28].
A study conducted by Han et al., 2020, examined
the relationship between the genre of online gambling and
IGD risk of erectile dysfunction in school- going
adolescents. The research subjects are only users of online
games and the general characteristics show that the
percentage of boys (67.7%) is higher than that of girls.
Overall, the rate of gambling use by gender tends to be
higher for men than for women. A 2015 survey of gaming
usage rates in the general population found that among all
online gaming users, the percentage of men was 66.3%, a
trend consistent with the current survey [16]. Meanwhile,
the prevalence of IGD in high-risk individuals was 10.1% in
this study, similar to the 11.5% and 9.0% reported by the
previous studies of IGD prevalence [25], [26]. However,
due to the differences in the tools is used in each study [29].
Research conducted byAlshehri and Mohamed, 2019
in Saudi Arabia shows that playing video games negatively
affects men’s health, social relationships, and physical
activity. The most negative endpoint was the correlation
between video games and physical activity (r = 0.49),
followed by social relationships (r = 0.42) and BMI (r =
0.31). The lowest results were in health (r = 0.20). More
empirical investigations are needed to explore the deeper
effects of video games on different groups in Saudi society,
including the general population, employees, and school
types, and different students [30].
In a study conducted by Deleuze et al., 2017
with participants who were players over 18
2 https://oamjms.eu/index.php/mjms/index
Systematic Review
attending universities in Belgium, questioned the validity of
the IGD DSM-5 Criteria using the original method of
multiple classifiers. This study requires further development
and refinement of the diagnostic criteria used to define the
IGD on a broader level. In particular, Deleuze et al. believe
that establishing a specific list of diagnostic criteria for IGD
also requires focusing on the unique psychological and
behavioral characteristics associated with the disease [31],
rather than simply exploiting the similarities with substance
abuse disorders. In addition, the diagnostic criteria must
make it possible to separate the increased healthy
association with the pathology to limit the risk of
pathologically normal behavior. Regarding the latter, the
latest guidelines provided by the World Health
Organization (WHO) (2017) in the beta version of the 11th
revision of the ICD appear to be an improvement, as they
do not include peripheral criteria and take explicitly take
into account the functional impairment as a mandatory
diagnostic criterion.
A study in Korea on the gap between self- report
and clinical diagnosis of IGD in adolescents conducted by
Jeong et al. 2018 concluded that the difference in
diagnosis was IGD between self- report and clinical
diagnosis reveals limits of self- measurement. Various
strategies are needed to fill the gap in self-assessment
methodology for IGD assessment. It is difficult to
accurately assess adolescents risk behaviors using self-
reported questionnaires. Adolescents at risk for various
disorders may not want to reveal specific facts about
themselves, and they may deliberately conceal risky
behavior that is not socially desirable. The effects of
social desirability can threaten the validity of the results
because the responses are systematically biased by
definition respondent, who wanted to present themselves in
a favorable condition, may or may not consciously adjust
their responses to make their behavior less deviant and
more social as the social desire bias causes players to
underreport their playing time to online games can also
signal a lack of time to play games for other reasons (e.g.,
losing track of time while immersed in an activity). The
way data are collected can influence the degree of social
desire bias may or may not consciously adjust their
responses to make their behavior less deviant and the more
social postulate that social desire bias causes gamers to
underreport their playing time. Individuals who play online
games may also underreport gaming time for other reasons
(e.g., lost track of time while immersed in an activity). The
way data are collected can affect the degree of social
desirability bias [32].
According to Volmer et al., 2014 research results
on adolescents in Turkey concluded that the types of
adolescents who play online games at night may be more
prone to computer game addiction than the types of
adolescents who play online games in the morning [33].

Risk factor of online game addiction
User motivation to play online games
The IGD risk factor is the user’s motivation
for play online games. Higher risk when the reason is to
relieve stress, and or avoid reality. This motive is associated
with specific games such as first-person shooters, which
play for skill and control, but a third of online
multiplayer games play (MMORPG) that players play to
relieve stress and deal with boring daily activities. Wanting
to escape reality is a necessary motivation when faced with
the problem of using online games. However, there are
serious gaps in research on the effects of online gaming, as
some studies have taken gaming platforms into account.
Most studies on the health effects of online gaming have
focused on the effects of online gaming on personal
computers, specifically the MMO battle arena games
MMORIX
240 (MOBAS). However, CVG smartphones like Candy
Crush Saga can be addictive because they can be played
anywhere and anytime for entertainment, connecting with
friends, enjoying the feeling of victory while relaxing or
killing time, and the use of these games is lonely and
lacks of self-control [18].
Types of online games
At present, the most popular video games are
MMO role-playing games (MMORPGs), flash games, and
online slots. MMORPGs are online role- playing game that
mainly focuses on fantasy stories or storyline conflicts. It is
about creating a digital avatar, an identity and an appearance,
and a virtual world where the players interact through their
avatar [3]. Yee’s three motivators in Goh et al., 2019 to
play MMORPG (Directing, Social Interaction, and Inclusion)
were tested as a mediator between playtime and
psychological well-being. Research found that an increase
in gaming was associated with lower psychological well-
being, especially when players had a greater incentive to
indulge and avoid, leading to a negative relationship
between alcohol use and addiction, using games to escape
real-life problems and poor mental health [34].
IGD and family relationship
Emerging evidence suggests that family
relationships play an important role and maybe one of the
risk/protective factors associated with the IGD that has been
explored as perceived family disharmony, parental
inconsistency, family dysfunction, poverty, and family
relationship problems [15].
From the study on “Multi-dimensional correlates
of IA symptoms in adolescents with
attention-deficit/hyperactivity disorder” conducted by Chou
et al. in some adolescents (11–18 years old) diagnosed with
ADHD (attention-deficit/hyperactivity disorder symptoms)
in Taiwan results show that low
Open Access Maced J Med Sci. 2021 Aug 03; 9(F):260-274.
Purwaningsih and Nurmala. Online Game Addiction on Adolescent Mental
satisfaction with family relationships was the most
important predicting of IA severe, followed by the use of
instant messaging (messenger), watching movies, the fun-
seeking system (behavioral approach system [BAS]), and
the Behavioral Inhibition System that scored high.
Meanwhile, poor father’s work, poor BAS drive, and
online gaming were significantly associated with severe IA
symptoms [35], [36]. While, ADHD symptoms include
inattention, hyperactivity, impulsivity, and oppositional
symptoms of oppositional (aggressive) disorders [36], [37].
The previous studies explored these aspects in subjects with
IGD and has led researchers to propose a classification of
different types of players. Lee and collaborators identified
three main types: Impulsive/aggressive gamers, emotionally
vulnerable players, and socially conditioned players [2].
Jia et al., 2021 summarize internet overuse’s
dynamic findings and clarify how peer transmission occurs
with Internet overuse behavior and peer attitudes toward
internet overuse [38]. According to Choi et al. 2018 in his
research showed the results that adolescents from dual-
income families had a significant relationship with all
factors of online game addiction and juvenile delinquency
[4].
Impact of the emergency room
Hui et al. 2019 wrote that online gaming is a
global concern, especially in China. According to the China
Internet Network Information Center, the number of
domestic online game players has increased from 336
million to 422 million in the past 5 years, achieving a growth
rate of 25%. Although recognized for recreational function of
online gaming, excessive and prolonged online gaming can
have adverse effects, including poor academic
performance, poor health, and feelings of loneliness, as well
as a lack of real relationships. More seriously and
specifically, online gamers may eventually develop an IGD,
which has been labeled as a condition for further
investigation in the DSM-5 and recognized as a new
mental health condition in the 11th WHO as a new mental
health problem, edition of the ICD-11. As high schools,
technical high schools, technical schools, and college
students make up the majority (55%) of Chinese online
game players, further research attention should be devoted
to reduce the risk of IGD on campus [39].
Kumcagiz’s research in Turkey showed the results
of a one-way ANOVA test that students whose fathers had
a low level of education were more likely to have higher
IA scores than students whose fathers had a high level of
education. The results of Pearson’s product-moment
correlation coefficient showed that students’ IA scores were
negatively correlated with age, mean grades, maternal care,
maternal overprotection, paternal overprotection, and
paternal overprotection. However, the stepwise regression
analysis results showed that the most important predictors
of IA
2
 F - Review
scores were maternal overprotection and paternal
overprotection; the results also show that age, mean grades,
maternal care, and paternal care [40].
Research by Lin et al., 2014 [41] on adolescents in
Taiwan showed that adolescents with IA were more likely
to have suicidal ideation and attempts. Given that IA is
associated with depression, low-income family support, and
low self-esteem, these factors increase the risk of suicide.
Treatment of online game addiction
Cognitive behavioral therapy (CBT)-
based manual treatment
In 2013, the APA included IGD in the fifth edition
of the DSM-5 [43] in the attachment to DSM 5, it is added
that the emergency department is included as a condition
that requires further research before being classified as an
official mental disorder [31]. The WHO in 2019 determined
that the IGD is one of the mental health disorders [43].
According to the two organizations, IGD disorder refers to
a minimum period of out-of-control behavior. The priority
is internet games such as online games and neglecting other
activities such as social activities, work, study, recreation,
and other important activities that cause adverse effects. In
adolescents, it can be in the form of decreased achievement,
lazy to study and others. Other technology-mediated behaviors
are thought to be linked to adverse mental health effects,
including the use of social media, smartphones, and online
pornography [1].
According to Wolfling et al., 2019, the long-term
treatment for internet and computer game addiction is
manual treatment based on CBT for 15 weeks for IA. This
model is based on the integrated process model of internet
addiction (InPRIA-model) which conceptualizes IA due to a
dynamic interaction of individual factors, online activity
features, dysfunctional coping strategies, and addiction-
specific cognitive biases. Treatment phase overview 15-
minute group sessions (100 min) and eight individual
sessions (60 min) interspersed in the program to promote
treatment motivation and provide crisis intervention. A
clinical psychologist carries out therapy or physical doctor
who has completed psychotherapy training and is
undergoing CBT training continued [43].
Many terms have been used to describe IGD in the
literature including internet game addiction, online game
addiction, computer game addiction, and pathological
game. Following the APA category, the term IGD is used in
the current article. The IGD as a newly proposed mental
disorder was not recognized by primary care providers
(PCPs) in its infancy. However, the IGD cannot be ignored
and is a severe health problem, likely to be underreported
and underestimated in clinical practice. PCPs from various
disciplines, including family physicians, mental health
counselors,
2 https://oamjms.eu/index.php/mjms/index
Systematic Review
and community nurses play an important role in the early
recognition and timely provision of IGD care [44].
IGD screening tools-TIG TOC and
instruments problematic internet use questionnaire
(PIQ)
In today’s modern era cannot be separated from
the internet and online games. However, it is important to
wisely control their use and distinguish between
problematic and non-problematic games to play, especially
for adolescent. There needs to be a screening tool that can
determine clinically and identify game disorders for
individuals who need professional help. When discussing
characteristics related to online game addiction problems,
one of the variables often mentioned is excessive use,
namely, the amount of time spent playing online games.
According to Sun et al., 2020, the sensitivity and specificity
of time spent playing online games do not adequately serve
as a screening tool to assess the risk of online gaming
disorder. The greatest strength of the current study is that
we evaluated the criteria-related validity of the TIGTOC
using a methodology that met the Quality Assessment of
Diagnostic Accuracy Studies tool — International quality
standards for diagnostic studies. To do so, a blind mental
health specialist conducted a one-on- one diagnostic
interview with all subjects to establish an IGD diagnosis
based on the DSM-5 criteria; this diagnosis is used as the
external gold standard. In this study, the empirical cutoff
score on the TIGTOC was sufficient to distinguish between
non-problematic and problematic use of online games. In
addition, Sun Je Jo found that TIG-TOC scores were
positively associated with weekly time spent playing online
games, measures of IA obtained through the IAT, ADHD
symptoms, and depressive symptoms; TIGTOC is a
reliable tool with a high Cronbach alpha. However, despite
the strength that the gold standard for ED diagnosis is
determined through such a rigorous process [11].
According to Rodda et al. [46], although evidence
suggests that most people self-medicate their IA, little is
known about the type, or efficacy, of the methods they
employ. Technology addiction may contribute to poor
academic performance and depression. This requires studies
on a larger scale, with interventions for judicious use of
gadgets [46].
A study in Japan provided evidence of the
Japanese version of the PIQ. In this study, the shortened form
of the PIUQ is the shortest continuous scale available to
assess PIU in Japan. Due to its concise and convenient format,
this newly translated measure will facilitate investigation of
PIU in the Japanese population and provide a screening tool
and allow cross-cultural comparisons. It will also be useful
for assessment in the evaluation, prevention, and treatment
of PIU in public health [47].

Policy recommendations
Approach to stakeholders
To prevent the emergence of problematic use of
technology and reduce harm, a multi-stakeholder
approaches such as researchers, doctors, regulators,
government agencies, community organizations, and
industry is used. Relevant government agencies and
industries that benefit from the implementation of online
games such as online gambling, have a duty to maintain,
social responsibility, and moral obligations to avoid
practices that can increase losses due to online gambling
games and take active steps to prevent and reduce the
hazards associated with them. Likewise, user protection
and prevention of harm are clinical and moral obligations
for professionals who work in online games and activities
that can potentially harm users. There is a need for user
information and behavioral prevention approaches adopted
in different countries, focusing on skill- building, protecting
users, limiting any harm, and simultaneously assessing
risky behavior. Community organizations and
governments should engage in education and awareness
campaigns to help technology users develop the skills and
behaviors critical of the content they consume and
develop safe practices such as boundary setting. There is a
need for user information and behavioral prevention
approaches adopted in different countries, focusing on skill-
building, protecting users, limiting any harm, and
simultaneously assessing risky behavior. Community
organizations and governments should engage in
education and awareness campaigns to help technology
users develop the skills and behaviors to be critical of the
content they consume and develop safe practices such as
boundary setting. There is a need for user information and
behavioral prevention approaches adopted in different
countries, focusing on skill-building, protecting users,
limiting any harm, and simultaneously assessing risky
behavior. Community organizations and governments
should engage in education and awareness campaigns
to help technology users develop the skills and behaviors to
be critical of the content they consume and develop safe
practices such as boundary setting.
Product design and consumer protection tools
To create norms around technology use behavior and
an understanding of the possible problematic use of
technology, an international perspective is essential as the
cultural context plays a major role. It is not enough to rely
on individual behavior for the prevention of harm ranging
from mild to severe, government organizations and
regulators must also act to prevent products, the
environment and marketing that may be too harmful for
those most vulnerable to problems
Open Access Maced J Med Sci. 2021 Aug 03; 9(F):260-274.
Purwaningsih and Nurmala. Online Game Addiction on Adolescent Mental
that will develop especially in young people and those with
mental health problems. For online gaming, there needs to
be establishing a framework for appropriate and non-
conforming product design and requirements for consumer
protection tools such as limiting in-game spending and
time. Research is needed that informs the suitability of
using certain digital technologies across user age groups
and implementing relevant user protections. Implications
for clinical practice include establishing dialogue among
experts in the field, including physicians, social workers,
educators, technology users, and other interested people. A
good balance must be struck where everyday behaviors are
not pathological and risky behaviors are identified and
prevented from developing into problematic behaviors. A
developmental perspective needs to be considered when
young users and behavioral problems need to be
contextualized according to the families involved in the
treatment [1]. In addition, providing information and
interventions appear to be a critical public health strategy
for preventing and addressing problems in all settings [49].
Promoting education on offline and online
health behavior in adolescent populations
The second policy is aimed at all Internet users,
especially those who appear to be at greater risk of
developing addiction problems related to internet use. All
the studies reviewed have highlighted the general aspects of
promoting healthy internet use, particularly among
adolescents and young adults, as some game genres are
highly demanding regarding competition and social
engagement (e.g., MMORPGs). Preventive measures that
can be taken include:
1. To encourage alternative motivation, involvement
in alternative entertainment behaviors (also those
including internet use), new coping skills, cognitive
and emotional skills, healthy attachment styles to
reduce the risk of internet use-related problems
and to reduce Internet use, if needed (e.g., through
alerts and notifications) and to provide alternative
relaxation options (e.g., reading, meeting people,
and engaging in physical activity)
2. To detect the risk of experiencing comorbidities or
other problems and address them with
professional support and the support of
significant others (e.g., caregivers in adolescents)
and embrace a systemic approach
3. Suppose there is a problem with internet use. In
that case, all Internet use-related addictions should
be assessed simultaneously, as many of the studies
reviewed were clinical studies on gaming
addiction, which together with gambling in young
adults appear to represent a worst-case scenario in
this regard [48].
2
 F - Review Systematic Review

AQ7 Figure 1: Research Area Map Wilayah

Discussion and higher rates of depression (r = 0.501), anxiety (r =

0.361) and psychoticism (r = 0.431), and lower family and
extra-family relationships (r = 0.383), and lower family and
Research studies around online game addiction and extra-family relationships (r = 0.383). In linear regression
its relationship to adolescent mental health are still very analysis, somatization (p = 0.002), depression (p =
limited. This systematic review study describes the above 0.001), and sleep disturbance (p = 0.003) were
topics regarding the health effects of the IGD in detail predictors of IGD diagnosis. IGD was significantly
starting from the type of IGD, IGD risk factors, and IGD associated with mental health disorders. In line with the
treatment. results of research by Beranuy et al., 2020, a positive and
significant relationship was found between IGDS9-SF
Figure 2 shows the areas where articles were (Internet gaming disorder short- form scale), CERM
published according to the inclusion criteria. The articles in (Mobile-related Experience), and OGD-Q (Online
this study come from three continents, namely, Asia, Gambling Disorder Questionnaire). Participants classified
Europe, and North America. with the IGD had a poorer health-related quality of life.
Almost all selected studies showed the same result, namely,
Screening

the existence of a significant relationship between the

Identificatio

The articles that identified during the search

werenumber
as follow: Pubmed database search were
The
20 articles,
deleted
of articles
Science
Pubmed
after
wasDirect
the duplication
18 articles,
19 articles,
was
Scopus
Science Direct
behavior of the emergency room and the mental health of
37 articles
keywords;was
and Sage
(online
8 articles
game(n
under
addiction)
the
was 18 articles, Scopus was 37 articles, Sage 3 Additional records, adolescents in particular.
8 articles = 80) AND reduplicated in
(mental health) AND (adolescent) (n = 81), Pubmed 1 article (n =
Table 3 shows seven observational study articles
Some articles that were excluded because they were irrelevant to the topic / could not be found in full text, not written in English, and reduplicated (n = 12)
on the impact of online game addiction on adolescent
Filtered Pubmed articles
were 13 articles, Science mental health. Five studies came from the Asian continent
Eligibit

Direct 16 articles, Scopus 36

articles, Sage 4 articles, (n =
Full text articles that are
considered eligible (n =
Include
(three from Japan, one Korea, and one Taiwan), and the
other two studies came from the North American continent
and the European continent (Mexico and Spain). Suppose
Some full texts of the articles were excluded because they were irrelevant to the topic, and
not in English (n = 44) adolescent play online and offline games excessively
without knowing the time. In that case, it can cause

adolescent to neglect other activities, even to eat, to have a

destructive impact on their nutritional status. According to
Studies included
in synthesis (n = psychologist Tara Adhisti de Thouars during the
Figure 2: PRISMA flow chart diagram lightHOUSE Indonesia media gathering at Wyl’s Kitchen
di Jakarta on Friday
In De Pascuale’s research, the data showed a
24 February 2017 inEvana Nisa’ul Ammar and Ira Nurmala
positive correlation between higher online game use
2020 eating disorders have a very serious impact, namely,
death, eating disorders themselves are a health problem that
contributes to high mortality rates in clinical cases of
mental disorders. The existence of

2 https://oamjms.eu/index.php/mjms/index
 Purwaningsih and Nurmala. Online Game Addiction on Adolescent Mental

AQ6 Table 2: Summary table of selected studies

Author Research design Sample Variable Results
De Pasquale et al. Quantitative 566 young adults (324 boys/242 Online game use, depression, The data showed a positive correlation between higher online
(2020) girls; ages 18–35 years: 22.74 ± anxiety, psychoticism, family game use and higher rates of depression (r = 0.501), anxiety (r =
4.83 years) in Italy relationships, sleep disorders, Data 0.361) and psychoticism (r = 0.431), and lower family and
collected by questionnaire Internet extra-family relationships (r = 0.431) (0.383). In linear regression
Gaming Distraction Scale Short analysis, somatization (p = 0.002), depression (p = 0.001) and sleep
Form (IGD9-SF); the APA symptom disturbance (p = 0.003) were predictors of ED diagnosis. ED was
checklist, based on significantly associated with mental health disorders
the DSM-5 diagnostic criteria for
the ED; Revised Symptom-90
Checklist (SCL-90 R); and the
Social Adaptation Self-Evaluation
Scale (SASS).
Beranuy et al. (2020) Quantitative 535 Vocational Training students in Mobile Phone-Related Experiences A positive and significant relationship was found between
Spain (mean age 18.35 years; SD (CERM), Internet Gaming Disorder IGDS9-SF, CERM, and OGD-Q. Participants classified with the ED had
± 2.13; 78.5% male) who reported Short Form Scale (IGD9-SF), Online a poorer health-related quality of life
playing video games in the last 12 Gambling Disorders Questionnaire
months (OGD-Q), and KIDSCREEN-27
with health-related quality of life

Nitin et al. (2018) a cross-sectional 1763 medical students aged Internet use behavior with Internet addiction is significantly and positively correlated with
study design 18 – 21 years in three cities in India psychological stress, especially psychological distress in medical students in India
depression
Wartberg and Quantitative 633 adolescent problematic alcohol use, Correlation analysis showed a statistically significant positive bivariate
Kammerl (2020) (median age: 15.79 years) in problematic gaming, problematic relationship between the four respective behavioral patterns. Antisocial
Germany social media use, problematic behavior is associated with all problematic behavior patterns. Meanwhile,
Internet use and mental health emotional distress, self-esteem problems and hyperactivity/inattention were
only associated with non-substance-
related problematic behavior patterns
Jo et al. (2020) Cohort Study 2319 teenage internet users in The Three-item-Online-Centered TIGTOC scores were positively associated with time spent playing
Korea Gaming Disorder Test (TIGTOC) online games, depressive symptoms, attention-deficit/hyperactivity
consists of three items using a four- disorder symptoms, and addictive internet use
point Likert scale selected from the
Internet Gaming Induced Symptoms
Screen
(I GUESS)
Lai and Kwan (2017) Quantitative 744 students from two Hong Kong Adolescent problematic Internet In particular, it was found that parental education and family income
secondary schools use and family socio-economic significantly moderated the relationship between the amount of Internet
variables use and the
severity of PIU
Kindt et al. (2019) longitudinal, 418 students aged between 11 and School-related factors such as This study shows the importance of school-related factors in the
randomized 21 years (M = 15.10, SD = 1.97), in absenteeism, school grades, development of the IUD, especially psychological factors that play a role
controlled study Germany procrastination, school-related in the school environment.
social behaviors, and learning
behaviors and IUD symptoms
(Internet use disorder)
Internet use variables (time spent
online and playing games) and
school-related psychological
variables (procrastination, learning
behavior, and social behavior) were
assessed through a self-
report questionnaire
González-Bueso Quantitative 66 ED adolescent patients were Subject’s Personality and Gaussian mixed model cluster analysis was used to classify subjects based
et al. (2020) referred consecutively at a mental Symptom Check List-90 items- on their personality. Two groups based on personality traits were
health center in Barcelona, Spain Revised, all State-Trait Anxiety detected: type I “high comorbid symptoms” (n
Index scales, and DSM-5 IGD = 24), and type II “low comorbid symptoms” (n = 42). Type I includes
criteria higher scores on the traits of introverted, inhibited, doleful, unruly, strong,
antagonistic, condescending and borderline tendencies, and lower scores
on traits histrionic, egotistical and conformable. Type
I scores higher on all 90-item Revised Symptom Check Lists, all
State-Trait Anxiety Index scales, and the ED DSM-5 criteria
Chou et al. (2014) Quantitative A total of 287 adolescents diagnosed Internet addiction, family The results showed that low satisfaction with family relationships was
with ADHD and aged between 11 and relationship satisfaction, instant the strongest predictor of severe internet addiction symptoms, followed
18 years in Taiwan messaging, watching movies, by instant messaging, watching movies, Behavioral Approach System
pleasure-seeking (BAS), Behavioral pleasure-seeking, and high Behavioral Inhibition System scores.
Inhibition System, SES, and online Meanwhile, SES (parental occupational socioeconomic status) low
gaming behavior father's occupation, low BAS drive,
and online gaming were also significantly associated with severe
internet addiction
Lin et al. (2021) Cross Sectional 320 adolescent and siblings Internet gaming disorder, The pair effect of the IGDS-SF9 score on depression, anxiety,
(Taiwan) psychological stress, and sleep stress, and insomnia severity was significant in both adolescents.
Männikkö et al. Cross Sectional 293 respondents aged 13-24 years in problematic gaming behavior, Problematic gaming behavior was associated with psychological and health
(2015) Finland psychological, social, and physical problems, namely fatigue, sleep disturbances, depression and anxiety
health symptoms symptoms. Multiple linear regression showed that weekly play volume,
depression and preference for online social interaction
predicted an increase in problematic gaming symptoms
Han et al. (2020) Cross-Sectional 1,532 high school students using High risk of Internet gaming disorder This cross-sectional study found an association between online game
online games in Seoul, Korea and online game genres genre and ED risk in adolescents who attend school
used by adolescent
Alshehri et al. (2019) Cross-sectional 194 respondents aged 17 .23 + 1.52 Behavior of playing electronic games The results showed that playing electronic games negatively correlated
survey study years in Saudi Arabia with health, social relationships, and with health, social relationships, and physical activity in men. The most
physical activity in men significantly negative was the correlation between electronic games and
physical activity (r = 0.49), followed by social relations (r = 0.42) and
BMI (r = 0.31). The lowest outcome was for
health (r = 0.20)
(Contd...)

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 F - Review Systematic Review

Table 2: (Continued)
Author Research design Sample Variable Results
Deleuze et al. (2017) Quantitative 97 late teenage gamers aged 18 – 39 Behavior of playing online games Comparisons using both approaches (DSM-5 and LCA) failed to identify
in Belgium with IGD criteria. The first is the significant differences in all constructs except for variables related to
classic DSM-5 approach (≥ 5 criteria actual or problematic game behavior
required to support an ED diagnosis). The validity of the ED criteria is questionable, largely concerning their
The second consists of using latent relevance in differentiating high involvement from pathological
class analysis (LCA) for ED criteria involvement in video games video
to differentiate
subgroups of gamers
Goh et al. (2019) Cross-Sectional 165 participants in the UK. amount of time spent playing Results show a significant correlation with higher levels of playtime
DOTA 2 (popular MOBA) and associated with poorer psychological well-being. The “runaway”
psychological well-being motivation partly mediates this relationship. Self-esteem found to
moderate the negative impact of “escape” games on psychological
well-being
Throuvala et al. Quantitative 225 young adults are members of the Parental acceptance-denial theory and The results showed that parental refusal was associated with the
(2019) UK’s online gaming community Internet gaming disorder and occurrence of ED, only through a CSE-mediated effect (core
Mediation and moderation of CSE self-evaluations)
Hui et al. (2019) Quantitative 200 young Chinese adults aged Impact of satisfaction and The results showed that relatedness dissatisfaction positively predicted
18–24 years (mean age = dissatisfaction on autonomy, ED symptoms after controlling for satisfaction and dissatisfaction with
19.48 years) competence, and relatedness in other needs. Also, progression was found to be negatively
explaining Internet gaming predicted by the ED
disorder
Kumcağız (2019) Quantitative 402 students aged 17 to 25 in Student internet addiction in One-way ANOVA results show that students whose fathers have a low
Turkey relation to parental attachment level of education are more likely to have higher internet addiction
and socio-demography scores than students whose fathers have a high level of education. The
results of Pearson’s product-moment correlation coefficient showed that
students’ internet addiction scores were
negatively correlated with age, mean grades, maternal care, maternal
overprotection, paternal overprotection, and paternal overprotection.
However, the results of the stepwise regression analysis showed that the
most important predictors of internet addiction score were
maternal overprotection and paternal overprotection
Buiza-Aguado et al. observational 708 students age 15.6 - 2.7 years Internet gaming addiction (ER), Multivariate analysis showed that IGD+ scores were significantly associated
(2018) transverse study were included. Malaga- South of health, psychosocial, gender, type of with poorer health and psychosocial adjustment (p < 0.001), whereas other
Spain game variables (male gender, online and MMORPG gaming,
and HG) were not significantly associated (p > 0.01)
Wölfling et al. (2019) A multicenter 143 men were randomized to either manual cognitive-behavioral Based on the theoretical model of IA, published and successfully pretested
randomized clinical the treatment group (STICA; n = 72) therapy (CBT), short-term short-term CBT (STICA19,20) was performed at 4 different sites. We
trial or the waiting list control group treatment for internet and included a male sample age, 26 years; range, 17 – 52 years) with addictive
(WLC) (n = 71). The main inclusion computer game addiction online and offline games or IA. This behavior addresses domains outside the
criteria were male gender and internet (STICA), individuals who are Gaming Disorders Category, which will also be provided by the forthcoming
addiction as the main diagnosis in addicted to the internet and International Classification of Diseases, 11th Revision; nevertheless, it shares an
Germany and Austria computer games understanding of behavioral disorders. A total of 52.4% of the patients had a
comorbid mental disorder (mainly mild to moderate depression), and 14.7%
received a
stable psychotropic drug regimen

serious psychological and medical conditions triggers a of suicide. Seeing that the emergency department is equated
person’s psychiatric condition, namely eating disorders with addiction diseases such as narcotics addiction, perhaps
[49]. According to research by Fernández- Villa et al., 2015 the same thing applied to recovery can also be done for
[24] found that a significant relationship between several IA, especially online games, as it is important to have
health problems (migraine, back pain, overweight or family support. This is under the results of a literature
obesity, and insufficient rest), psychological aspects (risk study by Devy Mulia Sari et al., 2021 on drug addicts.
of eating disorders, risk of mental disorders, and The existence of a good family role makes the recovery
depression), family problems and discrimination, without process more effective because a drug abuser will feel
any association with substance use (alcohol, marijuana, or motivated towards the support provided [50].
tobacco) was found. For some players, however, excessive
use fosters dependence which leads to negative Mental health is currently a problem faced by
psychosocial and health consequences. Research by Lin et adolescent, especially during the COVID-19 pandemic. The
al., 2014 on adolescents in Taiwan showed that adolescents use of social media by adolescent has also increased due to the
with internet addiction were more likely to have suicidal coronavirus pandemic. This situation risks an increased risk
ideation and attempts. Given that IA is associated with of a decline in adolescent mental health due to posting self-
depression, poor family support, and low self-esteem, presentations through social media such as Instagram.
these factors increase the risk Tateno in his research found that the trend of men
preferring games in their internet usage while women use
the internet mainly for social networking via smartphones,
and the average SAS-SV score (the SAS-Short Version)
AQ6 Table 3: The impact of online game addiction on adolescent
mental health higher in women, this is in line with the review Ferina
Author (year) Country Adjusted odd ratio 95% CI p-value Agustia Yuarta, Ira Nirmala, 2021 which shows the findings
Aguado et al. (2018)
Borges et al. (2019)
Spanish
Mexico
1.66
1.90
0.54 – 5.10
1.40 – 2.58
0.238
0.050
that social media users are mostly women as much as 51%
Han et al. (2020) Korea 1.52 1.03 – 2.24 0.001 while for men, 49% [51].
Kawabe et al. (2016) Japan 1.42 0.95 – 2.12 0.050
Kojima et al. (2018) Japan 1.81 1.11 – 2.95 0.010
Lin et al. (2014) Taiwan 1.21 1.05 – 1.39 0.002
Otsuka et al. (2019) Japan 2.39 1.36 – 4.20 < 0.001

2 https://oamjms.eu/index.php/mjms/index
 Purwaningsih and Nurmala. Online Game Addiction on Adolescent Mental

Figure 3: Forest plot the impact of online game addiction on adolescent mental health

To prevent the emergence of problematic use of mental health disorders by 1.57 times compared to
technology and reduce harm, a multi-stakeholder
adolescents who do not have online game addiction. The
approaches such as researchers, doctors, regulators,
results were statistically significant (p ≤ 0.001).
government agencies, community organizations, and
Heterogeneity (I2) = 53% indicates the spread of
industry is used. There is a need for health promotion about
the dangers of online game addiction in adolescents as an heterogeneous data (random effect model).
intervention measure. However, this is sometimes Figure 4 shows no publication bias indicated by
inconsistent between several stakeholders. This is following the symmetrical shape of the graph, there are three plots on
the qualitative research conducted by Mutmainah et al., the right and three plots on the left. The left plot has a
2020, which showed the results thatnot all stakeholders standard error of 0.2 to moderate. The plot on the right has a
have strong strength, positive attitude, and active interest in standard error between 0.6 and 0.2. The absence of bias can
developing adolescent health promotion media. Only two also be seen from the balanced distance between studies in
stakeholders (health sector and NGO) have a “savior” both the right and left plots.
category because these stakeholders have health programs.
Many stakeholders should be involved, but there is still
overlap in reality, and some stakeholders even say that it is
not important youth health promotion media. Stakeholder
providers tend to have weak power and passive interest
because media youth health promotion is usually given
directly from stakeholder decision makers [51]. The most
possible thing to do health promotion about the dangers of
online game addiction is with confidence in the sustainable
supporting factors recognizing the important role of
stakeholders to advocate the re-activation of peer educator
programs for high school students as a clear sign of support
[53].
Internet technology has dramatically changed
our daily lives and also changed the way we communicate. Figure 4: Funnel plot impact of online game addiction on adolescent
As social media apps become more popular, users are more mental health
closely connected to the internet and time spent with other
people in the real world decreases. Boys often isolate
themselves from the social community to engage in games
online while women use the internet to avoid being
ostracized addicted to the Internet and Smartphones for
Conclusion
their online communication. Mental health providers should
be aware of the seriousness of IA. Wise use of the internet
A systematic study conducted by researchers
is the only relevant prevention at this time to avoid the IGD.
focused on online game addiction and adolescent mental
Figure 3 shows the results of the forest plot of health. Articles based on specific inclusion criteria showed
the impact of online game addiction on adolescent mental a significant relationship between excessive online gaming
health. The results of the forest plot show that adolescents behavior (addiction) and adolescent mental health. Future
with online game addiction can increase researchers are expected to use this systematic review
study as a reference when trying to assess the impact of
excessive online gaming behavior on adolescent mental
health and relevant and clinically tested prevention and
treatment.

Open Access Maced J Med Sci. 2021 Aug 03; 9(F):260-274.

2
 F - Review
Author’s Contribution
Eni Purwaningsih is the main writer who selects
topics, searches and collects research data and analyze
research data; Ira Nirmala played a role in reviewing
articles.
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